Last month was the 16th International Menopause Society World Congress. This was held in Vancouver and I was fortunate to attend the meeting. This Congress was entitled “Dealing with midlife health in the 21st-century” and focused on problems of perimenopause and premature ovarian insufficiency in addition to menopause.

There were many international experts sharing their knowledge and experience. I find it very interesting to hear about the huge differences across the globe with respect to menopause treatment. There is still some resistance of HRT prescribing in America, which does seem to be related to a culture where the doctors are worried about potential litigation. In other countries, for example Paraguay, HRT is too expensive for women to be given it.

Oestrogen is a very important hormone in the female body. Reduced levels can clearly lead to hot flushes, but also various neurological symptoms including insomnia, mood changes, depression, cognitive dysfunction and suicidal ideation. Women who are symptomatic during their perimenopause can still be given hormones and the general consensus is that if they are having regular periods then they do not need to be given progesterone too.

HRT is not a “one size fits all” treatment, and various presentations throughout the Congress reiterated the safety of transdermal oestrogen regarding lower thromboembolic risk compared to oral oestrogen. The type of progestogen is very important too and there is now a large amount of evidence to support the use of micronised progesterone instead of other progestogens. Micronised progesterone is not associated with a risk of clots or cardiovascular disease and micronised progesterone does not increase proliferation by membrane-bound receptors on breast cancer which other progestogens seem to have. This means that it is not associated with same risk of breast cancer compared to other progestogens.

Prof Sue Davis, the new chair of IMS, gave a very informative lecture about managing women with symptoms of low testosterone. The audience was very divided regarding the potential benefits of giving testosterone to women but certainly there is evidence that low testosterone is associated with bone and muscle loss, reduced cognitive performance and lower libido. Testosterone is a safe hormone and it is reassuring that there is now a licenced preparation for women in Western Australia. It would be lovely if we could have a licenced preparation for women in UK soon.

The menopause is not just about symptoms, and the Congress included numerous presentations regarding risks of health to women during their menopause. Menopausal women have an increased risk of cardiovascular disease, osteoporosis and cognitive impairment. There is still a lack of awareness about this in women and also among physicians. I find this frustrating and sad especially as the numbers of menopausal women worldwide are increasing at a staggering rate. It is estimated that by 2025, around 1.1 billion women will have entered the menopause. Too many of these will not have their health risks addressed properly.

 

There is still some resistance of HRT prescribing in America, which does seem to be related to a culture where the doctors are worried about potential litigation

 

Two different experts talked about the role of mammography in breast screening and whether it is causing more harm than good. DCIS diagnosed by mammography has increased by 300% and less than 50% of women with DCIS progress to invasive breast cancer. For 10,000 women screened from the age of 50 for 20 years, it has been estimated that 43 deaths from breast cancer are reversed and 129 cases of breast cancer are overdiagnosed. This overdiagnosis can cause needless stress, anxiety, unnecessary treatment and also treatment-related complications.

Vulvo-vaginal atrophy is probably one of the worst treated conditions that I am aware of. Studies have shown that only around 7% of women with this condition are currently treated. There were numerous presentations on the treatment options for this condition and many of the treatments, either in isolation or in combination, can be very effective and really improve a woman’s quality of life. Mona Lisa Touch is a carbon dioxide laser, which has been shown in numerous studies to lead to increased proliferation of the epithelial cells, restore the vaginal epithelium and reduce atrophy.1

 

Research was presented which demonstrated that oophrectomy in younger women is associated with accelerated aging and an increased risk of numerous conditions including asthma, COPD, depression, dementia and hypertension

 

We know that women who have an early menopause need to be treated with hormones to reduce their future risk of heart disease, osteoporosis and early mortality. Research was presented which demonstrated that oophrectomy in younger women is associated with accelerated aging and an increased risk of numerous conditions including asthma, COPD, depression, dementia and hypertension.2 Much of this increased risk can be reduced by having adequate oestrogen. Too many young women with a surgical menopause are inadequately managed and this evidence supports how important it is that these women are not neglected and are given proper hormone replacement.

I attended two breakfast meeting with experts, which were useful opportunities to quiz them regarding practical management problems. One of these meetings was with Sue Davis who enlightened me further about prescribing testosterone for women.

I was fortunate to have the opportunity to present three pieces of research as posters.

One was the results of the questionnaire we undertook in the BJFM assessing health care professionals’ knowledge and understanding of the menopause and HRT. The second was results of a questionnaire undertaken by West Midlands Police looking at the impact of menopause in the workplace. The third one presented information based on the current literature regarding the optimal type of HRT – transdermal oestrogen and micronised progesterone.

It is very easy to sit in the lectures at large conferences like this one and forget the sheer number of women who are suffering worldwide as a result of inadequate menopause education of their own doctors. All the health care professionals attending this conference obviously have a large enthusiasm for helping menopausal women but they are the minority compared to their colleagues.

There needs to be a change in the perception of the menopause by women and also doctors – so away from the menopause as being seen as a “natural” condition we do not need to medicalise to thinking of the menopause as being a potential marker of future illness if not optimally managed. We all need to take responsibility for educating women and healthcare professionals so the menopause is a positive time in a woman’s life.

References

  1. Gandhi J, Chen A, Dagur G, Suh Y, Smith N3, et al. Am J Obstet Gynecol. 215(6): 704-711. Available at  https://www.ncbi.nlm.nih.gov/pubmed/27472999 [Last accessed July 2018]
  2. Rocca WA, Gazzuola-Rocca L, Smith CY, Grossardt BR, Faubion SS, et al. Mayo Clin Proc. 91(11):1577-1589. Available at https://www.ncbi.nlm.nih.gov/pubmed/27693001 [Last accessed July 2018]

 

Following its presentation at the IMS, the BJFM menopause survey was quoted in The Daily Mail. For more information visit http://www.dailymail.co.uk/health/article-5832523/Why-GPs-refuse-women-HRT.html


Dr Louise Newson

GP & Women’s Health Consultant Editor